A Qualitative Study of A Health Center-Based Mobile Produce Market

Healthcare-based food assistance programs have the potential to improve patients' food security, but are underutilized. We conducted a qualitative study of user and staff perceptions of an on-site mobile market at a federally-qualified health center (FQHC). Five themes were identified: 1) financial need drives the decision to use the market, 2) people attend specifically to receive healthy food, 3) users feel a connection to the FQHC, which increases participation, 4) social networks increase usage of the program, and 5) long lines, inclement weather, inaccessibility, and inconsistent marketing and communication are attendance barriers. Findings should inform implementation of future healthcare-based food assistance programs.

Factors Associated with Uptake of an Open Access Health Center-Based Mobile Produce Market: A Case for Expanded Eligibility

BACKGROUND

Healthcare-based food assistance programs show promise, but are underutilized. Strict eligibility requirements and program scheduling may dampen reach and outcomes.

OBJECTIVE

To explore factors associated with uptake of a health center-based mobile produce market with no eligibility requirements and few barriers to entry.

DESIGN

A cross-sectional analysis of medical record, socio-demographic, environmental, and market attendance data was used.

PARTICIPANTS/SETTING

The study sample consisted of 3,071 adults (18+ years) who were patients of an urban health center in eastern Massachusetts and registered for the mobile market during the study period of August 2016 to February 2020.

MAIN OUTCOME MEASURES

The main outcome measure was monthly market attendance over the study period.

STATISTICAL ANALYSES

T-tests and chi-squared tests were used to compare market users and never-users. Multiple logistic regression was used to analyze variables associated with market attendance each month.

RESULTS

In multiple variable analyses, SNAP enrollment was associated with slightly less frequent monthly market use (OR = 0.989 95% CI =0.984, 0.994). Day-of, on-site market registration was associated with more frequent monthly use than self-registration on non-market days (OR 1.08, 95% CI 1.07 to 1.08). Having a psychiatric or substance use disorder diagnosis was associated with slightly less frequent market attendance (OR 0.99, 95% CI 0.98 to 0.99, and OR 0.96, 95% CI 0.95-0.97, respectively) compared to registrants without these diagnoses.

CONCLUSIONS

Individual, community-level, and organizational factors are associated with uptake of a free mobile produce market, and should be considered when designing programs.

Caring Letters Sent by a Clinician or Peer to At-Risk Veterans: A Randomized Clinical Trial

Importance

Caring letters is an evidence-based suicide prevention intervention in acute care settings, but its outcomes among individuals who contact a national crisis line have not previously been evaluated.

Objective

To examine the outcomes of the Veterans Crisis Line (VCL) caring letters intervention and determine whether there are differences in outcomes by signatory.

Design, Setting, and Participants

This parallel randomized clinical trial compared signatories of caring letters and used an observational design to compare no receipt of caring letters with any caring letters receipt. Participants included veterans who contacted the VCL. Enrollment occurred between June 11, 2020, and June 10, 2021, with 1 year of follow-up. Analyses were completed between July 2022 and August 2023.

Intervention

Veterans were randomized to receive 9 caring letters for 1 year from either a clinician or peer veteran signatory.

Main Outcomes and Measures

The primary outcome measure was suicide attempt incidence in the 12 months following the index VCL contact. Incidence of Veterans Health Administration (VHA) inpatient, outpatient, and emergency health care use were secondary outcomes. All-cause mortality was an exploratory outcome. Wilcoxon rank-sum tests and χ2 tests were used to assess the differences in outcomes among the treatment and comparison groups.

Results

A total of 102 709 veterans (86 942 males [84.65%]; 15 737 females [15.32%]; mean [SD] age, 53.82 [17.35] years) contacted the VCL and were randomized. No association was found among signatory and suicide attempts, secondary outcomes, or all-cause mortality. In the analysis of any receipt of caring letters, there was no evidence of an association between caring letters receipt and suicide attempt incidence. Caring letters receipt was associated with increased VHA health care use (any outpatient: hazard ratio [HR], 1.10; 95% CI, 1.08-1.13; outpatient mental health: HR, 1.19; 95% CI, 1.17-1.22; any inpatient: HR, 1.13; 95% CI, 1.08-1.18; inpatient mental health: HR, 1.14; 95% CI, 1.07-1.21). Caring letters receipt was not associated with all-cause mortality.

Conclusions and Relevance

Among VHA patients who contacted the VCL, caring letters were not associated with suicide attempts, but were associated with a higher probability of health care use. No differences in outcomes were identified by signatory.

Trial Registration

isrctn.org Identifier: ISRCTN27551361.

Veterans Crisis Line Contacts After the 988 Suicide and Crisis Lifeline Rollout

INTRODUCTION

This study identifies changes in Veterans Crisis Line (VCL) contact volume following the 988 National Suicide Prevention Hotline rollout, and examines changes in contact volume for self-identified Veterans.

METHODS

VCL's Medora database was analyzed from July 2018 to June 2023, fitting linear interrupted time series models to forecast trends after the July 2022 rollout of the 988 Suicide Prevention Hotline. Data analysis was performed from 2023 to 2024.

RESULTS

After the 988 rollout, average monthly VCL contact volume increased by 5,388 contacts (8.2%). The number of contacts self-identifying as Veterans increased by 2,739 (6.2%), while the percentage of self-identifying Veteran contacts who could be linked to VHA records declined by 3.8%.

CONCLUSIONS

The 988 rollout was associated with increased VCL contact volume and broad changes in the profile of users. This underscores the importance of crisis services in adapting to dynamic user needs and highlights the potential of national suicide prevention initiatives to reach diverse populations.

Clinical effectiveness and cost-impact after 2 years of a ketogenic diet and virtual coaching intervention for patients with diabetes

AIM

We previously evaluated the impacts at 5 months of a digitally delivered coaching intervention in which participants are instructed to adhere to a very low carbohydrate, ketogenic diet. With extended follow-up (24 months), we assessed the longer-term effects of this intervention on changes in clinical outcomes, health care utilization and costs associated with outpatient, inpatient and emergency department use in the Veterans Health Administration.

MATERIALS AND METHODS

We employed a difference-in-differences model with a waiting list control group to estimate the 24-month change in glycated haemoglobin, body mass index, blood pressure, prescription medication use, health care utilization rates and associated costs. The analysis included 550 people with type 2 diabetes who were overweight or obese and enrolled in the Veterans Health Administration for health care. Data were obtained from electronic health records from 2018 to 2021.

RESULTS

The virtual coaching and ketogenic diet intervention was associated with significant reductions in body mass index [-1.56 (SE 0.390)] and total monthly diabetes medication usage [-0.35 (SE 0.054)]. No statistically significant differences in glycated haemoglobin, blood pressure, outpatient visits, inpatient visits, or emergency department visits were observed. The intervention was associated with reductions in per-patient, per-month outpatient spending [-USD286.80 (SE 97.175)] and prescription drug costs (-USD105.40 (SE 30.332)].

CONCLUSIONS

A virtual coaching intervention with a ketogenic diet component offered modest effects on clinical and cost parameters in people with type 2 diabetes and with obesity or overweight. Health care systems should develop methods to assess participant progress and engagement over time if they adopt such interventions, to ensure continued patient engagement and goal achievement.

Differences in adverse outcomes across race and ethnicity among Veterans with similar predicted risks of an overdose or suicide-related event

OBJECTIVE

To evaluate the degree to which differences in incidence of mortality and serious adverse events exist across patient race and ethnicity among Veterans Health Administration (VHA) patients receiving outpatient opioid prescriptions and who have similar predicted risks of adverse outcomes. Patients were assigned scores via the VHA Stratification Tool for Opioid Risk Mitigation (STORM), a model used to predict the risk of experiencing overdose- or suicide-related health care events or death. Individuals with the highest STORM risk scores are targeted for case review.

DESIGN

Retrospective cohort study of high-risk veterans who received an outpatient prescription opioid between 4/2018-3/2019.

SETTING

All VHA medical centers.

PARTICIPANTS

In total, 84 473 patients whose estimated risk scores were between 0.0420 and 0.0609, the risk scores associated with the top 5%-10% of risk in the STORM development sample.

METHODS

We examined the expected probability of mortality and serious adverse events (SAEs; overdose or suicide-related events) given a patient's risk score and race.

RESULTS

Given a similar risk score, Black patients were less likely than White patients to have a recorded SAE within 6 months of risk score calculation. Black, Hispanic, and Asian patients were less likely than White patients with similar risk scores to die within 6 months of risk score calculation. Some of the mortality differences were driven by age differences in the composition of racial and ethnic groups in our sample.

CONCLUSIONS

Our results suggest that relying on the STORM model to identify patients who may benefit from an interdisciplinary case review may identify patients with clinically meaningful differences in outcome risk across race and ethnicity.

Healthcare-based food assistance programmes in the United States: a scoping review and typology

This scoping review aimed to identify the breadth of healthcare-based food assistance programmes in the United States and organize them into a typology of programmes to provide implementation guidance to aspiring food assistance programmers in healthcare settings. We searched PubMed, Cochrane, and CINAHL databases for peer-reviewed articles published between 1 January 2010 and 31 December 2021, and mined reference lists. We used content analysis to extract programmatic details from each intervention and to qualitatively analyse intervention components to develop a typology for healthcare institutions in the United States. Eligible articles included descriptions of patient populations served and programmatic details. Articles were not required to include formal evaluations for inclusion in this scoping review. Our search resulted in 8706 abstracts, which yielded forty-three articles from thirty-five interventions. We identified three distinct programme types: direct food provision, referral, and voucher programmes. Programme type was influenced by programme goals, logistical considerations, such as staffing, food storage or refrigeration space, and existence of willing partner CBOs. Food provision programmes (n 13) were frequently permanent and leveraged partnerships with community-based organisations (CBOs) that provide food. Referral programmes (n 8) connected patients to CBOs for federal or local food assistance enrollment. Voucher programmes (n 14) prioritised provision of fruits and vegetables (n 10) and relied on a variety of clinic staff to refer patients to months-long programmes. Healthcare-based implementers can use this typology to design and maintain programmes that align with the needs of their sites and patient populations.

Impact of Mandated Case Review Policy on Opioid Discontinuation and Mortality Among High-Risk Long-Term Opioid Therapy Patients: The STORM Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

Although long-term opioid therapy (LTOT) has its own risks, opioid discontinuation could pose harm for high-risk Veterans Health Administration (VHA) patients receiving LTOT. There is limited information on the impact of a mandate requiring providers to perform case reviews on high-risk patients with an active opioid prescription (ie, mandated case review policy) on opioid discontinuation and mortality.

METHODS

Our study is a secondary data analysis of a 23-month stepped-wedge cluster randomized controlled trial between April 2018 and March 2020. The study included 10 685 LTOT patients with a predicted risk of a serious adverse event between the top 1% to 5% nationally who entered the risk range between 4/18/2018 and 11/9/2019. We examined whether the mandated case review policy had an impact on opioid discontinuation and mortality for the patients.

RESULTS

Among 10 685 LTOT patients (88.2% male; mean [SD] age, 61.1 [11.7] years), 29.1% experienced discontinuation and the mortality rate was 9.5%. Patients under mandated case review had a decreased risk of opioid discontinuation (average marginal effect [AME], -11.16 [95% CI, -15.30 to -7.01] percentage points) and all-cause mortality (AME, -3.31 [95% CI, -5.63 to -1.00] percentage points), relative to patients who were not under the mandate.

CONCLUSIONS

The VHA mandated case review policy was associated with lower probability of discontinuation and all-cause mortality for high-risk patients receiving LTOT. Interventions that maintain care engagement while optimizing pain management for high-risk patients may be beneficial for minimizing mortality and other risks associated with discontinuation.

Excess Mortality at Veterans Health Administration Facilities During the COVID-19 Pandemic

IMPORTANCE

The COVID-19 pandemic resulted in excess mortality among the general US population and at Veterans Health Administration (VHA) facilities. It is critical to understand the characteristics of facilities that experienced the highest and lowest pandemic-related mortality to inform future mitigation efforts.

OBJECTIVE

To identify facility-level excess mortality during the pandemic and to correlate these estimates with facility characteristics and community-wide rates of COVID-19 burden.

DESIGN

We used pre-pandemic data to estimate mortality risk prediction models using 5-fold cross-validation and Poisson quasi-likelihood regression. We then estimated excess mortality and observed versus expected (O/E) mortality ratios by the VHA facility from March to December 2020. We examined facility-level characteristics by excess mortality quartile.

PARTICIPANTS

Overall, there were 11.4 million VHA enrollees during 2016 and 2020.

MAIN MEASURES

Facility-level O/E mortality ratios and excess all-cause mortality.

RESULT

VHA-enrolled veterans experienced 52,038 excess deaths from March to December 2020, equating to 16.8% excess mortality. Facility-specific rates ranged from -5.5% to +63.7%. Facilities in the lowest quartile for excess mortality experienced fewer COVID-19 deaths (0.7-1.51, P <0.001) and cases (52.0-63.0, P =0.002) per 1,000 population compared with the highest quartile. The highest quartile facilities had more hospital beds (276.7-187.6, P =0.024) and a higher percent change in the share of visits conducted via telehealth from 2019 to 2020 (183%-133%, P <0.008).

CONCLUSIONS

There was a large variation in mortality across VHA facilities during the pandemic, which was only partially explained by the local COVID-19 burden. Our work provides a framework for large health care systems to identify changes in facility-level mortality during a public health emergency.

Effect of mental health staffing inputs on suicide-related events

OBJECTIVE

To estimate the effects of changes in Veterans Health Administration (VHA) mental health services staffing levels on suicide-related events among a cohort of Veterans.

DATA SOURCES

Data were obtained from the VHA Corporate Data Warehouse, the Department of Defense and Veterans Administration Infrastructure for Clinical Intelligence, the VHA survey of enrollees, and customized VHA databases tracking suicide-related events. Geographic variables were obtained from the Area Health Resources Files and the Centers for Medicare and Medicaid Services.

STUDY DESIGN

We used an instrumental variables (IV) design with a Heckman correction for non-random partial observability of the use of mental health services. The principal predictor was a measure of provider staffing per 10,000 enrollees. The outcome was the probability of a suicide-related event.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained for a cohort of Veterans who recently separated from active service.

PRINCIPAL FINDINGS

From 2014 to 2018, the per-pay period probability of a suicide-related event among our cohort was 0.05%. We found that a 1% increase in mental health staffing led to a 1.6 percentage point reduction in suicide-related events. This was driven by the first tertile of staffing, suggesting diminishing returns to scale for mental health staffing.

CONCLUSIONS

VHA facilities appear to be staffing-constrained when providing mental health care. Targeted increases in mental health staffing would be likely to reduce suicidality.

Effect of a Predictive Analytics-Targeted Program in Patients on Opioids: a Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)-a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide.

OBJECTIVE

To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans.

DESIGN

A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020.

PARTICIPANTS

A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event.

INTERVENTION

A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide.

MAIN MEASURES

Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality.

KEY RESULTS

Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65-0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64-7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39-0.61).

CONCLUSIONS

Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes.

TRIAL REGISTRATION

ISRCTN16012111.

Effect of a Veterans Health Administration mandate to case review patients with opioid prescriptions on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial

AIMS

The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high risk by STORM. The aim of this study was to measure the effect of this mandate on all-cause mortality and SAEs among VHA patients newly diagnosed with opioid use disorder (OUD).

DESIGN

Secondary analysis of a stepped-wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018 to 2020.

SETTING AND PARTICIPANTS

United States VHA facilities were randomized to case review the top 1 or 5% of high-risk patients prescribed opioid analgesics identified by STORM. A total of 28 251 patients were diagnosed with OUD during the trial and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post-hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation.

MEASUREMENTS

All-cause mortality and opioid-related, drug-related, suicide-related and other SAEs within 90 days of OUD diagnosis.

FINDINGS

Mandated case review increased the odds of 90-day mortality [odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.06, 2.87], but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all-cause mortality within 90 days was 5.87 (95% CI = 1.85, 18.58) relative to control patients.

CONCLUSIONS

Veterans Health Administration patients newly diagnosed with opioid use disorder experienced increased all-cause mortality following expansion of a case review mandate for high-risk patients prescribed opioids.

Randomized Policy Evaluation of the Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM)

BACKGROUND

The Veterans Health Administration (VHA) developed a dashboard Stratification Tool for Opioid Risk Mitigation (STROM) to guide clinical practice interventions. VHA released a policy mandating that high-risk patients of an adverse event based on the STORM dashboard are to be reviewed by an interdisciplinary team of clinicians.

AIM

Randomized program evaluation to evaluate if patients in the oversight arm had a lower risk of opioid-related serious adverse events (SAEs) or death compared to those in the non-oversight arm.

SETTING AND PARTICIPANTS

One-hundred and forty VHA facilities (aka medical centers) were randomly assigned to two groups: oversight and non-oversight arms. VHA patients who were prescribed opioids between April 18, 2018, and November 8, 2019, were included in the cohort.

PROGRAM DESCRIPTION

We hypothesized that patients cared for by VHA facilities that received the policy with the oversight accountability language would achieve lower opioid-related SAEs or death.

PROGRAM EVALUATION

We did not observe a relationship between the oversight arm and opioid-related SAEs or death. Patients in the non-oversight arm had a significantly higher chance of receiving a case review compared to those in the oversight arm.

DISCUSSION

Even though our findings were unexpected, the STORM policy overall was likely successful in focusing the provider's attention on very high-risk patients.

Effectiveness of a ketogenic diet and virtual coaching intervention for patients with diabetes: A difference-in-differences analysis

AIM

To test the effectiveness of a ketogenic diet and virtual coaching intervention in controlling markers of diabetes care and healthcare utilization.

MATERIALS AND METHODS

Using a difference-in-differences analysis with a waiting list control group-a quasi-experimental methodology-we estimated the 5-month change in HbA1c, body mass index, blood pressure, prescription medication use and costs, as well as healthcare utilization. The analysis included 590 patients with diabetes who were also overweight or obese, and who regularly utilize the Veterans Health Administration (VA) for healthcare. We used data from VA electronic health records from 2018 to 2020.

RESULTS

The ketogenic diet and virtual coaching intervention was associated with significant reductions in HbA1c (-0.69 [95% CI -1.02, -0.36]), diabetes medication fills (-0.38, [-0.49, -0.26]), body mass index (-1.07, [-1.95, -0.19]), diastolic blood pressure levels (-1.43, [-2.72, -0.14]), outpatient visits (-0.36, [-0.70, -0.02]) and prescription drug costs (-34.54 [-48.56, -20.53]). We found no significant change in emergency department visits (-0.02 [-0.05, 0.01]) or inpatient admissions (-0.01 [-0.02, 0.01]).

CONCLUSIONS

This real-world assessment of a virtual coaching and diet programme shows that such an intervention offers short-term benefits on markers of diabetes care and healthcare utilization in patients with diabetes.

County-Level Impact of the COVID-19 Pandemic on Excess Mortality Among U.S. Veterans: A Population-Based Study

BACKGROUND

As the novel coronavirus (COVID-19) continues to impact the world at large, Veterans of the US Armed Forces are experiencing increases in both COVID-19 and non-COVID-19 mortality. Veterans may be more susceptible to the pandemic than the general population due to their higher comorbidity burdens and older age, but no research has examined if trends in excess mortality differ between these groups. Additionally, individual-level data on demographics, comorbidities, and deaths are provided in near-real time for all enrolees of the Veterans Health Administration (VHA). These data provide a unique opportunity to identify excess mortality throughout 2020 at a subnational level, and to validate these estimates against local COVID-19 burden.

METHODS

We queried VHA administrative data on demographics and comorbidities for 11.4 million enrolees during 2016-2020. Pre-pandemic data was used to develop and cross-validate eight mortality prediction models at the county-level including Poisson, Poisson quasi-likelihood, negative binomial, and generalized estimating equations. We then estimated county-level excess Veteran mortality during 2020 and correlated these estimates with local rates of COVID-19 confirmed cases and deaths.

FINDINGS

All models demonstrated excellent agreement between observed and predicted mortality during 2016-2019; a Poisson quasi-likelihood with county fixed effects minimized median squared error with a calibration slope of 1.00. Veterans of the U.S. Armed Forces faced an excess mortality rate of 13% in 2020, which corresponds to 50,299 excess deaths. County-level estimates of excess mortality were correlated with both COVID-19 cases (R²=0.77) and deaths per 1,000 population (R²=0.59).

INTERPRETATION

We developed sub-national estimates of excess mortality associated with the pandemic and shared our data as a resource for researchers and data journalists. Despite Veterans' greater likelihood of risk factors associated with severe COVID-19 illness, their excess mortality rate was slightly lower than the general population. Consistent access to health care and the rapid expansion of VHA telemedicine during the pandemic may explain this divergence.

FUNDING

This work was supported by grants from the Department of Veterans Affairs Quality Enhancement Research Initiative [PEC 16-001]. Dr. Griffith's effort was supported in part by the Agency for Healthcare Research & Quality [K12 HS026395].

Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis

INTRODUCTION

The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined.

METHODS

A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008-2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18-64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020.

RESULTS

In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= -16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment.

CONCLUSIONS

Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.

Peer effects of obesity on child body composition

This study investigates whether peer obesity is a driver of individual weight changes in public school children and whether the impact of peer effects changes as children age. Quantifying peer effects is important for understanding the social determinants of obesity and for planning effective school wellness policies. However, the extant empirical research on peer effects is limited due to difficulties in separating causal influences from confounding factors. This study overcomes some of these difficulties by using a within-school, across-cohort empirical design to separate confounding factors at the individual, school and school-grade level for over one million public school children. The results show that increases a one standard deviation increase in average classmate body mass index (BMI) leads to a modest but meaningful increase of 0.395 standard deviation increase in a child's own BMI. Peer-effects are highest (0.813) for children in Kindergarten and decline with age. These findings suggest that the critical time for school-grade level intervention may be in the earliest ages of childhood development.

Adolescent Cognitive Aptitudes and Later-in-Life Alzheimer Disease and Related Disorders

IMPORTANCE

Low early-life cognitive ability is a potential early marker of dementia risk in later life. Previous studies use only global measures of general intelligence and/or study this relationship in gender-specific samples. The contribution of early-life performance on specific cognitive abilities, such as language, reasoning, and visualization aptitudes, to indicating future dementia risk is unknown.

OBJECTIVES

To investigate the association between adolescent cognitive ability and Medicare-recorded Alzheimer disease and related disorders (ADRD) using both general and specific measures of cognitive ability and to explore these associations separately in men and women.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study from the Project Talent-Medicare linked data set, a linkage of adolescent sociobehavioral data collected from high school students in 1960 to participants' 2012 to 2013 Medicare Claims and expenditures data. The association between adolescent cognitive ability and risk of ADRD in later life was assessed in a diverse sample of 43 014 men and 42 749 women aged 66 to 73 years using a series of logistic regressions stratified by sex, accounting for demographic characteristics, adolescent socioeconomic status, and regional effects. Data analysis was conducted from November 2017 to March 2018.

MAIN OUTCOMES AND MEASURES

Presence of Medicare-reported ADRD.

RESULTS

Overall, 1239 men (2.9%) and 1416 women (3.3%) developed ADRD. Lower mechanical reasoning was associated with increased odds of ADRD in men (odds ratio, 1.17; 95% CI, 1.05-1.29), and lower memory for words in adolescence was associated with increased odds of ADRD in women (odds ratio, 1.16; 95% CI, 1.05-1.28). Lower performance on several other language, reasoning, visualization, and mathematic aptitudes in adolescence showed prominent, but weaker, associations with odds of ADRD.

CONCLUSIONS AND RELEVANCE

This work contributes to the understanding of early-life origins of ADRD risk. The results suggest specific measures of cognitive ability may contribute to very early identification of at-risk subgroups who may benefit from prevention or intervention efforts.

Food prices and obesity: a review

In response to rising rates of obesity in the United States due in part to excess food consumption, researchers and policy makers have argued that levying food taxes on obesity-promoting foods, perhaps combined with subsidies on healthier options, would be an effective tool to stem the obesity epidemic. The extent to which overall energy intake or weight outcomes will improve as a result of these policies is ultimately an empirical question. This review examines the link between food or beverage price changes and energy intake or weight outcomes among U.S. consumers. Current evidence indicates that, by themselves, targeted food taxes and subsidies as considered to date are unlikely to have a major effect on individual weight or obesity prevalence. While research suggests that the effects are modest, food taxes and subsidies may play an important role in a multifaceted approach to reducing obesity incidence.

Mandatory menu labeling in one fast-food chain in King County, Washington

BACKGROUND

As part of a comprehensive effort to stem the rise in obesity, King County, Washington, enforced a mandatory menu-labeling regulation requiring all restaurant chains with 15 or more locations to disclose calorie information at the point of purchase beginning in January 2009.

PURPOSE

The purpose of this study is to quantify the impact of the King County regulation on transactions and purchasing behavior at one Mexican fast-food chain with locations within and adjacent to King County.

METHODS

To examine the effect of the King County regulation, a difference-in-difference approach was used to compare total transactions and average calories per transaction between seven King County restaurants and seven control locations focusing on two time periods: one period immediately following the law until the posting of drive-through menu boards (January 2009 to July 2009) and a second period following the drive-through postings (August 2009 through January 2010). Analyses were conducted in 2010.

RESULTS

No impact of the regulation on purchasing behavior was found. Trends in transactions and calories per transaction did not vary between control and intervention locations after the law was enacted.

CONCLUSIONS

In this setting, mandatory menu labeling did not promote healthier food-purchasing behavior.

The economics of obesity

The rise in obesity rates, both nationally and internationally, is a result of changes in the environment that have simultaneously lowered the cost of food production, lowered the time and monetary cost of food consumption, increased the real cost of being physically active at work and at home, and decreased the health consequences that result from obesity by bringing a host of new drugs and devices to the market to better manage the adverse health effects that obesity promotes. This changing environment is in response to consumers' demand for labor-saving technology and convenient, affordable food. To be successful, efforts to combat obesity therefore need to recognize and address these realities.